This document discusses endotracheal tubes and intubation. It covers indications for intubation including airway protection, optimizing gas exchange, decreasing metabolic demand, and reducing work of breathing. Conditions associated with difficult intubation are described such as congenital anomalies, infections, tumors, injuries, and obesity. Proper equipment, tube sizing, intubation technique including positioning and confirmation of placement are outlined. Golden rules of intubation emphasize preparation, oxygenation, skills, confirmation, and monitoring.

1. ENDOTRACHEAL
TUBES
and INTUBATION
Dr Nisar Ahmed Arain
Assistant Professor
Anesthesia/Critical Care/ER

2. -INDICATIONS
--A =Airway Protection
=Optimization of gas exchange
--B
=Oxygenation / Ventilation
=To Decrease Metabolic Demand
--C
=To Reduce work of breathing

3. -INDICATIONS
=Airway protection
=Decrease LOC
=Lower cranial nerve palsy
A
=Laryngeal edema
=Orofacial injury
=Copious trachea-bronchial
secretions

4. -INDICATIONS
=Optimization of Gas exchange
Oxygenation / Ventilation
B =Hypoxic Respiratory Failure
Pneumonia / Pulmonary edema/ARDS
=Hyperbaric respiratory failure
Obstructive airway disease/ OSAS
Obesity hypoventilation syndrome

5. -INDICATIONS
=To decrease metabolic demand/
To decrease WoB
-C
=Severe septic shock / Burn /
polytrauma

6. -Anatomy of airway

7. -Conditions associated with difficult intubation
-Congenital anomalies
Pierre Robin Syndrome, Down’s Syndrome
-Infection in airway
Retropharyngeal abscess, epiglottis
-Tumor in oral cavity or Larynx
-Enlarge thyroid causing compression / displacement
of trachea

8. -Conditions associated with difficult intubation
--Maxillofacial cervical of laryngeal trauma
--Temporomandibular joint dysfunction
--Burn scar at Face and Neck
--Morbidly obese or pregnancy

9. -Airway assesment
-Inter Incisor distance > 3 cm

10. -Airway assesment
-Mallampati classification
--Difficult Intubation

11. -Airway assesment
-Laryngoscopy View
-Difficult Intubation

12. -Airway assesment
-Thyro mental distance > 6 cm
-Difficult Intubation

13. -Airway assesment
-Flexion / Extension of Neck

14. -Airway Assesment
-Movement of Temporomandibular joint (TMJ)
-GRINDING

15. -EQUIPMENTS
--Laryngoscope with relevant size blade
--Magill's Forceps
--Flexible Introducer
--10 to 20 ml syringe
--Oropharyngeal airways –All sizes
--Tape or adhesive Plaster
--E.T tubes--relevant sizes
--Bag—Valve—Mask with oxygen connected
--Suction unit with Yankauer nozzle and
endotracheal suction catheter

16. -Laryngoscope

17. -Laryngoscope

18. -Endotracheal tube

19. -Oropharyngeal / Nasopharyngeal Airway

20. -Endotracheal Tube: Size( mm Internal Diameter)
--New Born—3 Months = 3.0 mm ID
--3 to 9 Months = 3.5 mm ID
--9 to 18 Months = 4.0 mm ID
--2 Years to 6 Years = (Age/3) + 3.5
-- >6 Years = (Age/4) + 4.5
--Adult Male = 8 to 8.5 mm ID
--Adult Female =7.0 to 7.5 mm ID

21. -Depth of endotracheal tube : should be placed at
Mid trachea or below vocal cords = 2 cms
--Adult -> Male = 23 cms
--Adult -> Female = 21 cms
--Children
a- Oral endotracheal tube = (Age/2) + 12 cms
b- Nasal endotracheal tube = (Age/2) + 15 cms

22. -Technique of endotracheal Intubation
The three Axis : Oral, Pharyngeal and Laryngeal

23. -Sniffing Position : Aligning the three Axis

25. -Technique of endotracheal Intubation
--Position the patient supine, open the airway with
a head- tilt-chin-lift maneuver.
(suspected spinal injury, attempt Nasotracheal intubation
spine in neutral position
--Open mouth by separating the lips and pulling on
upper jaw with the index finger

26. -Technique of endotracheal Intubation
--Hold laryngoscope in the left hand, insert scope into the mouth with blade directed to right tonsil.
--Once right tonsil is reached, sweep the blade to the midline keeping the tongue on the left.
--This brings the Epiglottis into view. “DO NOT LOOSE SITE OF IT “
--Advance the blade until it reaches the angle between the base of the tongue and
epiglottis (Vallecular space)
--Lift the laryngoscope upwards and away from the Nose – towards the chest. This should
bring the vocal cords into view. It may be necessary for a colleague to press on the trachea
to improve the view of the larynx

27. -Technique of endotracheal Intubation cont.
--Place the ETT in the right hand. Keep the concavity of the tube facing the right side
of the mouth
--Insert the tube watching it enter through the cords.
--Insert the tube just so the cuff has passed the cords and then inflate the cuff
--Listen for air entry at both apices and both axillae to ensure correct placement
using stethoscope

28. -CONFIRMATION OF PROPER TUBE PLACEMENT
--PLACEMENT UNDER VISION
--FOUR QUADRANT AUSCULTATION
--CAPNOMETERY / CAPNOGRAPHY
--VENTILATOR GRAPHS

29. --GOLDEN RULES OF
INTUBATION
--Always have a suction unit available
--An intubation attempt should never exceed 30 seconds
--Oxygenate the patient Pre and Post intubation with a Bag-valve-Mask
and monitor SpO2 continuously
--Have sedative / analgesic medicines available
--Always confirm tube placement by more then one methods
--Do not attempt intubation unless you are totally skilled, rather perform
Bag-Valve-Mask Ventilation
--Always confirm tube placement from time to time